Term
| is delirium a predictor of increased mortality? |
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Definition
| yes - up to 1 year after hospitalization. |
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Term
| what are the 3 C's of delirium? |
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Definition
| consciousness, cognition, and course. |
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Term
| what characterizes consciousness in delirium? |
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Definition
| unaware of surroundings and disruption of attention (*separates from dementia*) |
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Term
| what characterizes cognition in delirium? |
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Definition
| difficulty w/recent memory, registration, knowing who people are, disorientation, and language difficulties. |
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Term
| what characterizes course in delirium? |
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Definition
| abrupt with fluctuations (waxing/waning) |
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Term
| do most physicians know what delirium looks like? |
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Definition
| no - delirious pts often get sent to a psych hospital, when they need to be sent to the ER (considered a medical emergency). |
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Term
| what is the #1 tx for delirium? |
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Definition
| haldol. also ativan/atypicals. |
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Term
| what is the pathophysiology of delirium? |
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Definition
| decreased ACh (usually suppresses DA levels), increased DA (causes the language/memory/orientation/fluctuation of attention problems - target for tx), and disordered melatonin levels (delta sleep is not present - not the same w/dementia). |
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Term
| what are structural etiologies for delirium? |
|
Definition
| CVA, intracranial lesion, subdural hematoma |
|
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Term
| what are infectious etiologies for delirium? |
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Definition
| urosepsis (common in elderly pts), pneumonia, and CNS infections such as AIDS defining infections |
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Term
| what are metabolic etiologies for delirium? |
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Definition
| hyper/hyponatremia, hyper/hypoglycemia, hyper/hypocapnia, hyper/hypocalcemia, hypoxia (esp in COPD/emphysema), and alcohol withdrawal |
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|
Term
| what are iatrogenic etiologies for delirium? |
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Definition
| BZDs (often overused), anticholinergics (often overused), analgesics, H2 blockers, digoxin, antiepileptics, and steroids |
|
|
Term
| how is delirium assessed? |
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Definition
| confusion rating scale, clinical assessment of confusion, delirium rating scale etc. CAM-ICU for ventilated pts. |
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Term
| what are risk factors for pts in the ICU? |
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Definition
| HTN, smoking hx, bilirubin level, morphine/ativan use, and rooms w/o windows. |
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|
Term
| what characterizes delirium in ventilated pts? |
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Definition
| this carries a 3x risk of death (after controlling for co-morbidities, illness, severity, coma, and medication use). |
|
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Term
| what are the 4 basic principles in delirium tx? |
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Definition
| *tx underlying condition, avoid casual factors, support to prevent further physical/cognitive decline, and control aggressive behaviors. |
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|
Term
| what characterizes use of haldol in tx of delirium? |
|
Definition
| this DA2 receptor blocker is primary tx for delirium @ low doses as it corrects the underlying neurochemical issue (increased DA). |
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|
Term
| can BZDs help w/delirium? |
|
Definition
| *only if the delirium is due to alcohol withdrawal (used in alcohol withdrawal because it is a GABA-ergic, hyperglutamatergic situation which can be reversed by BZDs). otherwise BZDs have no effect on the neurochemical imbalance, disinhibit the pt and add to memory issues. |
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Term
| what characterizes the atypical antipsychotics in tx of delirium? |
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Definition
| zyprexa and risperidol have been shown to be as efficacious as haldol, but haldol is cheaper, safer (less side effects), and can be used in lower doses. |
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|
Term
| what characterizes consciousness in delirium vs dementia? |
|
Definition
delirium: decreased or hyper alert
dementia: alert |
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|
Term
| what characterizes orientation in delirium vs dementia? |
|
Definition
delirium: disorganized thought
dementia: disoriented (but lack disorganized thought) |
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|
Term
| what characterizes course in delirium vs dementia? |
|
Definition
delirium: fluctuating (moments where ok, mistaken for psychosis)
dementia: steady slow decline |
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|
Term
| what characterizes onset in delirium vs dementia? |
|
Definition
delirium: acute/ sub-acute
dementia: chronic |
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|
Term
| what characterizes attention in delirium vs dementia? |
|
Definition
delirium: impaired, can’t sustain shift or focus attention
dementia: usually normal |
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|
Term
| what characterizes psychomotor in delirium vs dementia? |
|
Definition
delirium: usually agitated, but possibly lethargic as in renal failure (high mortality in lethargic delirious patients because don’t present as a problem or get attention)
dementia: usually normal |
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|
Term
| what characterizes hallucinations in delirium vs dementia? |
|
Definition
delirium: perceptual disturbances common
dementia: usually not present, exception of the rule when occur |
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|
Term
| what characterizes sleep-wake-cycle in delirium vs dementia? |
|
Definition
delirium: abnormal
dementia: normal |
|
|
Term
| what characterizes speech in delirium vs dementia? |
|
Definition
delirium: slow, incoherent
dementia: aphasic, anomic, difficulty finding words |
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|
Term
| what are the inherited types of dementia? |
|
Definition
| wilson disease, adrenoleukodystrophy, and gaucher disease |
|
|
Term
| what characterizes wilson disease? |
|
Definition
| this is an autosomal recessive disease which leads to *hepato-lenticular degeneration: copper deposits in the liver and lenticular nucleus (globus pallidus and putamen) of the basal ganglia due to a decrease in the enzyme which binds copper to ceruloplasmin. pts will have myoclonic movements, memory deficits, language problems, and dementia over time. often seen in young pts. dx: *kayser-fleischer rings (around iris) and *decrease in serum ceruloplasmin. |
|
|
Term
| what is adrenoleukodystrophy? |
|
Definition
| in this x-linked disease, fatty acid chains deposit in the CNS, adrenal glands and testes = early onset dementia. |
|
|
Term
|
Definition
| a deficiency in glucocerebrosidase which results in lysosomal packaging problems = lipid deposits in the spleen, liver, kidney, lung, and CNS = dementia at an early age. |
|
|
Term
| what are the toxic metabolic types of dementia? |
|
Definition
| wernicke-korsakoff, B12 deficiency, hypothyroidism, and hypercalcemia |
|
|
Term
| what can lead to hypercalcemia and thus dementia? |
|
Definition
| paraneoplastic syndrome (small cell lung CA). if Ca++ goes above certain levels = dementia, which when the Ca++ imbalance is treated, goes away. |
|
|
Term
| can hypothyroidism present as severe memory problems? |
|
Definition
| yes, which is usually hashimoto's |
|
|
Term
| how does B12 deficiency lead to dementia? |
|
Definition
| B12 is necessary for glial cells and nutritional support of neuronal bodies. neurons in the diencephalon and mamillary bodies are particularly vulnerable to B12 deficiency (*memory problems). B12 deficiency also leads to pernicious anemia. gastric bypasses can cause B12 deficiency. |
|
|
Term
| what is wernicke delirium/korsakoff dementia? |
|
Definition
| wernicke: potentially reversible delirium due to thiamine (B1) deficiency characterized by *ataxia and *disconjugate gaze (affects medial longitudinal fasiculus). may occur if alcoholic gets dextrose before thiamine. korsakoff: potentially reversible dementia due to thiamine deficiency characterized by thiamin deficiency over a long period of time affecting the mammillary bodies and diencephalon = *memory problems which the pt will often confabulate to fill in. |
|
|
Term
| what are the degenerative types of dementia? |
|
Definition
| alzheimer's (most common overall dementia), vascular, lewy body, parkinson's, frontotemporal (pick disease), and huntington's |
|
|
Term
| what characterizes alzheimer's disease? |
|
Definition
| this, most common form of dementia is progressive to incapacity and death. initially newly aquired info is lost, then later language, abstraction and executive functioning. 20% have delusions and hallucinations. only a clinical dx, can only be confirmed by autopsy. neuroimaging is nonspecific (dilated lateral ventricles, widening of cortical sulci, mild atrophy - hypometabolism in temporal and parietal lobes). genetics: APP on chr 21, presenilin 1 on chr 14, presenilin 2 on chr 1, and APOE on chr 19 (polygenetic disease). pathology: atrophy of cerebral cortex (frontal/temporal/parietal), earliest cell loss in entorhinal area, basal nucleus of meynert cell loss (ACh center in brain), senile/beta amyloid plaques, and neurofibrillary tangles. tx: acetylcholinesterase inhibitors. |
|
|
Term
| what characterizes dementia due to vascular disorders? |
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Definition
| this is the second leading cause of dementia. it is due to a series of ischemic strokes occurring in key areas of the brain (basal ganglia, lenticulate nucleus) affecting memory, executive function, behavior. risk increases 5% per year after ischemic strokes. vascular dementia has the soft symptoms of memory problems (like alzheimers), but also the hard symptoms of focal weakness/aphasia/dysnomia which can be used to localize the stroke. |
|
|
Term
| what characterizes parkinsons/lewy body dementia? |
|
Definition
| parkinsons: alzhiemer disease changes, lewy bodies (cortical/subcortical intracytoplasmic inclusions esp in basal ganglia), and *primary nigral degeneration. lewy body dementia: *rapid cognitive decline, visual hallucinations, parkinsonism (cogwheel rigidity, resting tremor, postural instability, akinesia/bradykinesia), and sensitivity to neuroleptics (like haldol - b/c already low on DA). |
|
|
Term
| what characterizes frontotemporal dementia? |
|
Definition
| this is rare. mutations on chr 17 (tau gene). initial presentation (unique to this dementia): personality changes, speech disturbances, inattentiveness, +/- extrapyramidal signs, atrophy of the frontal, then temporal poles, and deterioration of memory/executive function. also pick bodies (intraneuronal) may be present as pick disease is a type of frontotemporal dementia. |
|
|
Term
| what characterizes huntington disease? |
|
Definition
| trinucleotide/CAG repeats, autosomal dominant, symptoms start at 35-40, choreic movements (proximal/distal/axial - caudate nucleus degeneration), personality changes, and dementia. there is a genetic phenomenon called anticipation w/huntingtons where symptoms come on earlier and become more severe from one generation to the next. |
|
|
Term
| what characterizes creutzfeldt-jakob disease? |
|
Definition
| this is due to prions (proteinaceous infective agents/no DNA/RNA) which cause *myoclonus, *periodic EEG complexes (sharp waves), and *dementia. often seen in elderly pts. |
|
|
Term
| what are the infectious types of dementia? |
|
Definition
| HIV dementia complex and prion related disease (CJD, gerstmann-straussler-scheinker, fatal familial insomnia) |
|
|
Term
| what characterizes HIV dementia complex? |
|
Definition
| apathy, memory loss, *cognitive slowing before other neurologic changes (but is also subcortical), neurological abnormalities, frontotemporal atrophy, *multinucleated giant cells, *microglial nodules, and *perivascular infiltrates. on imaging: cortical atrophy (often seen in young pts). tx: supportive. |
|
|
Term
| what are the reversible dementias? |
|
Definition
| B12/folate deficiency (increased incidence w/gastric bypasses), neuroborreliosis (cognitive deficits, memory problems, behavioral issues, depression), neurosyphillis (latent infection, tx:PCN), normal pressure hydrocephalus (magnetic gait, due to clogged arachnoid vestibules), hypothyroidism, and major depression (pseudodementia) |
|
|
Term
| what generally characterizes the amnestic disorders? |
|
Definition
| memory loss w/preserved intellect due to injury or dysfunction of the hippocampus/other parts of limbic system. may be transient or permanent. |
|
|
Term
| what characterizes the transient amnestic disorders? |
|
Definition
| wernicke-korsakoff/blackouts, head trauma (concussions), medications (any GABA-ergic: BZDs, barbiturates, anticonvulsants), partial complex seizures (post-ictal phase), transient global ischemia (vascular insufficiency of the temporal lobes = limbic ischemia), and ECT |
|
|
Term
| what characterizes the permanent amnestic disorders? |
|
Definition
| wernicke/korsakoff, HSV encephalitis, severe head trauma (contusions) , kluver-bucy (congenital absence of temporal lobe), and paraneoplastic limbic encephalitis (usually small cell lung CA). |
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